Supporting Peer Support Workers and Their Supervisors: Cluster-Randomized Trial Evaluating a Systems-Level Intervention

OBJECTIVE

Peer support workers are a substantial and growing part of the mental health workforce. Because little research has investigated how to effectively support and supervise peer support workers, the authors evaluated the efficacy of a training program to strengthen the peer support workforce and the supervision of its workers.

METHODS

Mental health services sites with peer support workers and supervisors in Los Angeles County were recruited for this cluster-randomized trial and 10-month follow-up. Of 348 peer support workers and 143 supervisors at 85 sites, 251 (72%) peer support workers and 115 (80%) supervisors completed baseline surveys. SHARE! the Self-Help And Recovery Exchange, a peer-run organization, delivered four training sessions on strategies to reduce stigma and to build an effective peer workforce, cultural competence, and a trauma-informed developmental model of supervision. Primary outcomes were peer-supportive organizational climate, mental health stigma, and peer support worker recovery.

RESULTS

Intention-to-treat analyses indicated that sites receiving the training had significantly higher scores on peer-supportive organizational climate (Cohen's d=0.35, 95% CI=0.02-0.68, p=0.04) relative to sites not receiving the training. No significant differences were found between the two conditions for mental health stigma (Cohen's d=0.04) or peer support worker recovery (Cohen's d=0.14).

CONCLUSIONS

The training had no impact on mental health stigma or peer support worker recovery. However, the findings suggest that the training increased the value organizations gave to peer support work, which may help improve peer support worker retention and outcomes among those served. Efforts to incorporate principles of the training into practice may strengthen outcomes.

Nutrition and Health Programming and Outreach in Grocery Retail Settings: A Community Coalition in Action

Grocery stores can provide a conducive environment for interventions targeting healthy eating and access to health services, particularly in low-income communities. A wide array of organizations deliver nutrition and related programs in community settings, but rarely in a coordinated fashion. Collaboration of local health promotion organizations with grocery stores could increase consumers' access to and selection of healthy foods and related services. This evaluation of the In-Store Programming and Outreach Coalition (IPOC) uses thematic analysis of first-person accounts from coalition members. To our knowledge, this is the first study of such a coalition. We present perspectives from six stakeholders about the IPOC strengths, challenges, and recommendations for strengthening the delivery of in-store interventions. Themes identified include partnership, increased client reach and cross-referrals, conflicting work schedules, leadership, and recommendations to identify coalition leaders and expand services to other grocery stores. We conclude that grocery stores can offer a suitable setting for programming and community outreach through coalitions.

Vales+Tú: a cluster-randomized pilot study to reduce workplace injuries among US Latino day laborers

Latino day laborers (LDL) are a vulnerable population of workers facing considerable risk for occupational injury. Under the guidance of our Community Advisory Board, we developed and tested the feasibility, acceptability and preliminary effects of Vales+Tú (You Are Worth More), a workplace injury risk-reduction program implemented by promotores on street-corners where LDL seek employment. The program was informed by theoretical perspectives emphasizing individual and group agency and self-determination. A pilot three-arm cluster-randomized community trial was conducted among 75 LDL. The intervention arms consisted of an individualized Brief Motivational Interview, a Group Problem Solving activity and a standard of care control (OSHA safety cards). We met our study goal of 25 LDL per intervention arm, and contacted 88% of participants post intervention. Participants evaluated the interventions favorably. At post-test, the Brief Motivational Interview group reported significant reductions in exposure to workplace hazards and increases in risk-reduction practices. The Group Problem Solving participants showed significant reductions in exposure to hazards (t-test −4.16, p < 0.001). Both intervention groups increased their reliance on corner peers, a measure of social support. Standard of care participants increased in self-efficacy to work safely. Overall, the only significant different between the three study conditions was in self-efficacy. These findings provide evidence of the feasibility and acceptability of Vales+Tú and show preliminary program efficacy. A large-scale replication trial will permit a more formal modeling of the study findings. Clinical Trial Registration (ClinicalTrials.gov): NCT04378348.

Predictors of e-cigarette initiation and use among middle school youth in a low-income predominantly Hispanic community

Introduction

E-cigarette use among middle and high school youth increased from 2. 5 million in 2014 to 9.2 million in 2019, becoming the most common tobacco product used among youth. Hispanic youth, the largest ethnic minority in the United States, have higher rates of tobacco use, including e-cigarettes, than non-Hispanics. Identifying factors that put youth at risk for future e-cigarette use is vital to focusing prevention efforts. Informed by social cognitive theory, this study identifies predictors of e-cigarette uptake among e-cigarette naïve youth in a predominantly low-income Hispanic community.

Methods

1,249 students (6-8th grades) from two middle schools in El Paso, Texas consented to participate in this longitudinal survey during the 2016-2017 school year. The study sample for analysis was restricted to e-cigarette naïve students (n = 862). Outcome measures were e-cigarette initiation and current use at follow-up. Logistic regression models tested six hypotheses about predictors of e-cigarette initiation and current use: (1) intention, (2) outcome expectations, (3) knowledge, (4) friendship network exposure, (5) normative beliefs, and (6) social acceptability.

Results

Among e-cigarette naïve students at baseline, 8% (n = 71) reported initiation at follow-up; of these, 3% (n = 23) reported current use. Significant predictors of initiation were intention (AOR = 2.46; 95% CI 1.69-3.59; p < 0.001), outcome expectations (AOR = 1.73; 95% CI 1.14-2.61; p = 0.009), friendship network exposure (AOR = 1.53; 95% CI 1.11-2.11; p =0.01), normative beliefs (AOR = 2.12; 95% CI 1.47-3.08; p < 0.001), and social acceptability (AOR = 1.91; 95% CI 1.28-2.85; p = 0.002). Significant predictors of current use were intention (AOR = 1.98; 95% CI 1.07-3.69; p = 0.03) and friendship network exposure (AOR = 1.69; 95% CI 1.06-2.70; p = 0.03).

Conclusions

With the increasing popularity of e-cigarettes, age appropriate and culturally sensitive prevention strategies tailored at altering these predictive factors are essential in preventing future e-cigarette use.

Association Between Adverse Childhood Experiences, Resilience and Mental Health in a Hispanic Community

This study explores the relations between adverse childhood experiences (ACEs), mental health and resilience among Hispanic adults living in the United States - Mexico Border region. Numerous studies have investigated the negative impact of ACEs on adult mental health, but the concept of resilience as a protective factor for mental health in the Hispanic communities has limited consideration in ACE treatment interventions. The proposed study addresses this gap in knowledge by investigating relations between ACEs, resilience, and mental health. An online survey was administered to 221 university students to assess the relationship between ACEs, mental distress and resilience. Using hierarchical linear regression, three models were estimated. First, including demographics, second including ACEs and low resilience, followed by the interaction of ACEs and resilience. Analyses indicate that ACEs were associated with mental distress (B = 1.02, 95% CI 0.37 - 1.68, p < 0.01) and low resilience was associated with mental distress (B = 5.37, 95% CI 3.15 - 7.59, p < .01). The interaction between ACEs and low resilience was also related to mental distress (B = 1.32, 95% CI 0.17 - 2.47, p = 0.03), indicating that ACEs had a larger association with mental distress among respondents with low resilience. Findings highlight the importance of the direct association between resilience and mental distress, along with the moderating influence of resilience on the relation between ACEs and mental health. Interventions promoting resilience may be effective in reducing mental distress, especially among individuals with a history of ACEs.

Sheep recombinant IGF-1 promotes organ-specific growth in fetal sheep

IGF-1 is a critical fetal growth-promoting hormone. Experimental infusion of an IGF-1 analog, human recombinant LR3 IGF-1, into late gestation fetal sheep increased fetal organ growth and skeletal muscle myoblast proliferation. However, LR3 IGF-1 has a low affinity for IGF binding proteins (IGFBP), thus reducing physiologic regulation of IGF-1 bioavailability. The peptide sequences for LR3 IGF-1 and sheep IGF-1 also differ. To overcome these limitations with LR3 IGF-1, we developed an ovine (sheep) specific recombinant IGF-1 (oIGF-1) and tested its effect on growth in fetal sheep. First, we measured in vitro myoblast proliferation in response to oIGF-1. Second, we examined anabolic signaling pathways from serial skeletal muscle biopsies in fetal sheep that received oIGF-1 or saline infusion for 2 hours. Finally, we measured the effect of fetal oIGF-1 infusion versus saline infusion (SAL) for 1 week on fetal body and organ growth, in vivo myoblast proliferation, skeletal muscle fractional protein synthetic rate, IGFBP expression in skeletal muscle and liver, and IGF-1 signaling pathways in skeletal muscle. Using this approach, we showed that oIGF-1 stimulated myoblast proliferation in vitro. When infused for 1 week, oIGF-1 increased organ growth of the heart, kidney, spleen, and adrenal glands and stimulated skeletal myoblast proliferation compared to SAL without increasing muscle fractional synthetic rate or hindlimb muscle mass. Hepatic and muscular gene expression of IGFBPs one to three was similar between oIGF-1 and SAL. We conclude that oIGF-1 promotes tissue and organ-specific growth in the normal sheep fetus.

Initial conditions and functioning over time among community coalitions

Developing operationally strong community coalitions is critical to actualizing their potential for public health improvement. The purpose of this study was to measure how substance use prevention coalitions in Mexico functioned across their first 1.5 years, and to test associations between initial community contextual factors and subsequent coalition functioning and outcomes. Members of 19 coalitions participated in three waves of surveys about coalition context and functioning. We used paired t-tests to assess changes in coalition functioning and outcomes. Regression models estimated associations between coalition functioning and outcomes and initial community context. Among coalition functioning factors, over coalitions' first 1.5 years, member engagement increased, as did coordinator skill and participatory leadership style. Two initial community context factors - community support for prevention and community champions - predicted several measures of process competence, but only community champions predicted perceived community improvement. Thus, community champions may play a pivotal role in later coalition success. The observed increases in member engagement and process competence may support subsequent coalition sustainability, a crucial component to realizing their potential impact on public health.

Differences in body composition and growth persist postnatally in fetuses diagnosed with severe compared to mild fetal growth restriction

BACKGROUND

Fetal growth restriction (FGR) is most commonly diagnosed in pregnancy if the estimated fetal weight (EFW) is <  10th%. Those with abnormal Doppler velocimetry, indicating placental insufficiency and pathological FGR, demonstrate reduced fat and lean mass compared to both normally growing fetuses and FGR fetuses with normal Dopplers. The aim of this study was to determine how severity of FGR and abnormal Doppler velocimetry impacts neonatal body composition. Among a cohort of fetuses with an EFW <  10th%, we hypothesized that those with abnormal Dopplers and/or EFW <  3rd% would have persistent reductions in lean body mass and fat mass extending into the neonatal period compared to fetuses not meeting those criteria.

METHODS

A prospective cohort of FGR fetuses with an estimated fetal weight (EFW) <  10th% was categorized as severe (EFW <  3rd% and/or abnormal Dopplers; FGR-S) versus mild (EFW 3-10th% ; FGR-M). Air Displacement Plethysmography and anthropometrics were performed at birth and/or within the first 6-8 weeks of life.

RESULTS

FGR-S versus FGR-M were born one week earlier (P = 0.0024), were shorter (P = 0.0033), lighter (P = 0.0001) with smaller weight-for-age Z-scores (P = 0.0004), had smaller head circumference (P = 0.0004) and lower fat mass (P = 0.01) at birth. At approximately 6-8 weeks postmenstrual age, weight, head circumference, and fat mass were similar but FGR-S neonates were shorter (P = 0.0049) with lower lean mass (P = 0.0258).

CONCLUSION

Doppler velocimetry abnormalities in fetuses with an EFW <  10th% identified neonates who were smaller at birth and demonstrated catch-up growth by 6-8 weeks of life that favored fat mass accretion over lean mass and linear growth.

Addressing Hispanic Obesity Disparities Using a Community Health Worker Model Grounded in Motivational Interviewing

PURPOSE

To determine whether Hispanic residents receiving the Healthy Fit intervention enhanced with Motivational Interviewing (MI) experienced greater improvements in body composition, relative to participants receiving the initial intervention.

DESIGN

Quasi-experimental evaluation.

SETTING

El Paso, Texas.

SAMPLE

Among 656 baseline participants, 374 (54%) completed the 12-month assessment.

INTERVENTION

In Healthy Fit, community health workers (CHWs) promote nutrition and exercise. To strengthen intrinsic motivation and help participants overcome barriers to change, we incorporated a 30-minute motivational interview into the baseline assessment. Follow-up phone calls at 1, 3, and 6 months were identical across conditions.

MEASURES

CHWs assessed body mass index (BMI) and body fat percentage (BFP) using a bioelectrical impedance scale.

ANALYSIS

Regression models estimated differences between intervention conditions on change in BMI and BFP from baseline to the 12-month assessment.

RESULTS

Participants receiving MI had 2.13 times higher odds of losing weight (OR = 2.14, 95% CI [1.30, 3.53], P = .003) and 2.59 times higher odds of reduced BFP (OR = 2.59, 95% CI [1.51, 4.41], P < .001), relative to initial intervention participants. MI participants lost an average of 1.23 kg (2.71 lbs.) and their BFP declined 2% over 12 months.

CONCLUSION

Findings suggest CHW use of MI is a promising approach for promoting incremental changes in diet and exercise, which Healthy Fit integrates into a low-cost intervention.

Protocol for a hybrid type 3 cluster randomized trial of a technical assistance system supporting coalitions and evidence-based drug prevention programs

BACKGROUND

Over 5000 community anti-drug coalitions operating in the USA serve as a cornerstone of federal drug prevention. These coalitions, however, have demonstrated effectiveness in preventing substance use only when they use technical assistance (TA) and implement evidence-based programs (EBPs). The absence of TA and EBP implementation by coalitions is a key research-to-practice gap. The Coalition Check-Up TA system is designed to fill this gap by supporting community coalition implementation of EBPs. Existing TA models for evidence-based coalition approaches are resource intensive and coalition model specific. The Coalition Check-Up is a lower cost strategy that works with a variety of types of coalitions to support sustainable implementation of EBPs. This study protocol describes a hybrid type 3 effectiveness-implementation trial applying Wandersman's Interactive Systems Framework to test the effects of the Coalition Check-Up on coalition EBP implementation capacity and outcomes. The Interactive Systems Framework outlines how the prevention support system-especially TA-bolsters EBP dissemination and implementation.

METHODS

Using a cluster randomized controlled design, this trial will test the overall effectiveness of the Coalition Check-Up, including how it contributes to EBP implementation and prevention of youth substance use. The first aim is to estimate the impact of the Coalition Check-Up on coalitions' capacity to do their work. We will recruit 68 anti-drug coalitions for random assignment to the Coalition Check-Up or "TA as usual" condition. We will evaluate whether the Coalition Check-Up improves coalition capacity using measures of coalition member responses about team processes, coalition network composition, and collaborative structure. Our second aim is to estimate the impact of the Coalition Check-Up on implementation of EBPs, and our third aim is to estimate the impact of the Coalition Check-Up on youth substance use.

DISCUSSION

This project will clarify how the Coalition Check-Up, a scalable approach to TA due to its low cost, affects coalition capacity to support EBP implementation. Analyses also provide insight into causal pathways from the prevention support system to the prevention delivery system outlined by the Interactive Systems Framework. Results will build the evidence-base for how to support community coalitions' sustainable implementation of evidence-based prevention programs and policies.

TRIAL REGISTRATION

Clinicaltrials.gov registration number NCT04592120 . Registered on October 19, 2020.

Body composition outcomes of Healthy Fit and the role of acculturation among low-income Hispanics on the US-Mexico border

BACKGROUND

Hispanic immigrants continue to experience higher rates of overweight and obesity compared to their non-Hispanic counterparts. Acculturation may contribute to unhealthy weight gain among immigrant populations by shifting dietary patterns from high fruit and vegetable consumption to unhealthier high fat diets. Healthy Fit, a culturally tailored community health worker (CHW) intervention, aims to reduce obesity related outcomes by providing physical activity and nutrition education and resources in a low-income Hispanic population. This study aims to evaluate outcomes of Healthy Fit participants and examine changes in body composition in relation to level of acculturation at baseline and follow-up.

METHOD

In this longitudinal observational study, CHWs recruited 514 participants from community events and agencies serving low-income Hispanic populations in El Paso, Texas from 2015 to 2016. Following an in-person health screening, eligible participants received nutrition and physical activity education guided by fotonovelas, comic-like educational books. Telephone follow-ups made at 1, 3, and 6 months by CHWs encouraged follow-through on referrals. 288 participants completed the screening again during the 12-month follow-up.

RESULTS

The sample was predominantly Hispanic (96%), female (82%), uninsured (79%), had a household income of less than $19,999 (70%), foreign-born (79%), preferred Spanish (86%) and few rated themselves as good or excellent for English proficiency (27%). Overall, Healthy Fit participants significantly improved (i.e., decreased) BFP by 0.71% (t = 2.47, p = 0.01) but not BMI (b = .01, t = - 0.14, p = .89). Contrary to expectations, acculturation was not associated with lower BMI (b = 0.09, p = 0.84) or BFP (b = 0.13, p = 0.85) at baseline. However, acculturation predicted changes in both BMI (b = 0.30, p = 0.03) and BFP (b = 1.33, p = 0 .01) from baseline to follow-up. Specifically, the low acculturation group improved in body composition measures over time and the high acculturation group did not improve in either measure.

CONCLUSION

Findings suggest Healthy Fit was most effective among less acculturated individuals. The influence of acculturation on the efficacy of nutrition and exercise interventions suggests that Hispanics should not be treated as a homogenous subgroup.

Promoting Hispanic Immigrant Health via Community Health Workers and Motivational Interviewing

Hispanic immigrant health disparities are among the highest in the nation, especially related to obesity and access to health services. Healthy Fit (En Forma Saludable) is a health promotion program that leverages public health department infrastructure to address these disparities through the use of three key innovations explored in this article: community health workers (CHWs), motivational interviewing (MI), and vouchers for free preventative health services. CHWs trained in MI conduct a health screening and then distribute preventive service vouchers and health resources as needed based on screening results. Vouchers cover breast, cervical, and colorectal cancer screening, and several vaccinations including flu and human papillomavirus. Resources to support exercise, to support a healthy diet, to quit smoking, and to reduce risky drinking are also distributed as needed. CHWs then use MI to address perceived barriers and strengthen intrinsic motivation to make use of the health resources. Integrating these strategies provides a low-cost approach to promote healthy behavior in an underserved immigrant population.

Documenting and Understanding Workplace Injuries Among Latino Day Laborers

BACKGROUND

Latino day laborers face substantial injuries at work. We present a comprehensive assessment of their injury experience and explore the predictors of selfreported injuries.

METHODS

Worker and injury characteristics were collected from 331 day laborers using an innnovative injury assessment tool. The odds of injury were estimated using a logistic regression.

RESULTS

Participants were foreign-born, Spanish monolingual, and employed in construction. Sixty-seven individuals reported 88 past-year injuries, mostly involving the upper or lower extremities. Injuries were caused by moving heavy objects, falling, or being struck an object. Of the documented injuries, 24% were not reported at work due to fear of being fired; 64.4% resulted in missed workdays, 54.0% in temporary incapacitation, and 34.5% in permanent incapacitation. Being married significantly reduced the odds of reporting an injury.

DISCUSSION

Better documentation can inform the development of better policy protections that ameliorate injuries experienced by Latino day laborers at the workplace.

Attitudes toward tobacco among low-income Hispanic adolescents: Implications for prevention

Background: Although US cigarette smoking rates have steadily declined, the changing nature of nicotine consumption and the popularity of non-combustible nicotine products urges us to revise tobacco prevention strategies. Research on smoking perspectives among Hispanic youth is limited yet crucial for prevention efforts with Hispanics being the largest minority in the U.S.Objective: This study sought to understand the experience and perceptions of low-income Hispanic youth regarding tobacco use.Methods: Forty-nine adolescents (ages 9 to 19) from El Paso, Texas, participated in five extended focus group discussions about tobacco/nicotine use.Results: Adolescents were predominantly exposed to tobacco through relatives, although school and party contexts became more relevant as youth aged. Youth had negative perceptions of tobacco and smokers, but believed their peers often viewed tobacco positively. Youth also saw tobacco use as a functional stress-management strategy, especially within their extended family. Health and family were strong motivators not to smoke.Conclusions: Youth maintain several tensions in their views on tobacco. Tobacco use is considered unpleasant and harmful, yet youth perceive their peers to view it as cool. Peer to peer discussion of tobacco experiences and perceptions may help correct these incongruent viewpoints. Adding to this tension is the perception that tobacco is used to manage stress. Given the importance of the home environment for Hispanic youth, tobacco prevention efforts may benefit from engaging family to identify the ways in which tobacco use causes stress.

Cluster Randomized Trial of Teens Against Tobacco Use: Youth Empowerment for Tobacco Control in El Paso, Texas

INTRODUCTION

This study examines smoke-free youth partnerships implementing the Teens Against Tobacco Use model developed by the American Lung Association. This innovative tobacco prevention strategy has not been evaluated rigorously. Students used peer teaching to educate youth about tobacco use and engaged in tobacco control advocacy activities. Participating high school and middle school youth were trained to develop and deliver tobacco prevention presentations to 4th-8th grade students in schools.

STUDY DESIGN

To evaluate the efficacy of the presentations, matched pairs of classrooms willing to have 1 presentation were randomly assigned to receive either the presentation first (intervention condition) or later in the school year (control condition).

SETTING/PARTICIPANTS

The study took place in a predominantly low-income Hispanic community. A total of 9 schools, 107 classes, and 2,257 students participated in the evaluation.

MAIN OUTCOME MEASURES

Tobacco susceptibility was assessed with a brief survey administered to students in both intervention and control classrooms in 2014 and 2015 after the completion of presentations in intervention classrooms. Analyses completed in 2019 compared intervention and control classrooms on tobacco susceptibility.

RESULTS

Intent-to-treat analyses indicated that classrooms receiving a tobacco prevention presentation had significantly lower tobacco susceptibility scores than classrooms that did not receive a presentation (12% vs 17%, p<0.01), representing a 37% reduction in the odds of tobacco susceptibility. Teens Against Tobacco Use presenters also completed tobacco retailer compliance checks and gained media coverage in advocating to regulate e-cigarettes in the same manner as other tobacco products.

CONCLUSIONS

Findings suggest Teens Against Tobacco Use is an effective means of reducing tobacco susceptibility among 4th-8th graders in the immediate term. Longer-term outcome evaluations are needed to determine whether Teens Against Tobacco Use presentations can have a lasting impact on tobacco use.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02443025.

Using a reasoned action approach to identify determinants of organized exercise among Hispanics: a mixed-methods study

Background

Research on Hispanics’ activity preferences suggest that they prefer engaging in group-oriented physical activities, such as organized exercise. Yet, little is known about pathways to participation in organized exercise among Hispanics. This study used a reasoned action approach (RAA) framework to explore beliefs and determinants of organized exercise among Hispanics. Specifically, we examined the impact of participants’ intentions on reported organized exercise behavior, and the relation between intentions and attitudes, subjective norms, perceived behavioral control, and self-efficacy.

Methods

Our mixed-methods study was part of a larger pre-post design intervention study. Participants completed an interview containing open- and closed-ended questions to identify salient beliefs and practices about attending organized exercise activities. We conducted two separate regression models to assess the effects of intentions on behavior (n = 330) and the associations of RAA constructs on intentions (n = 101), both adjusting for demographics. Qualitative analysis of a sub-sample (n = 105) of responses to open-ended questions identified salient beliefs related to organized exercise attendance.

Results

Our results showed that intentions predicted behavior at follow up (IRR = 2.03, p < .05), and that attitudes and perceived behavioral control were associated with intentions (β = .36, p < .05; β = .36, p <. 05, respectively). Qualitative findings suggest participants value health and the behavioral benefits of attending organized exercise activities; feel approval from family and friends; and identify transportation, time, distance, and costs as factors that influence their attendance to organized exercise activities.

Conclusions

Consistent with theoretical expectations, we identified statistically significant determinants of intentions and attendance to organized exercise. Findings can inform the development of persuasive messages and interventions to promote exercise in low-income Hispanic populations facing obesity disparities.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7527-1) contains supplementary material, which is available to authorized users.

Integrating Journalism Into Health Promotion: Creating and Disseminating Community Narratives

Media coverage of mental health and other social issues often relies on episodic narratives that suggest individualistic causes and solutions, while reinforcing negative stereotypes. Community narratives can provide empowering alternatives, serving as media advocacy tools used to shape the policy debate on a social issue. This article provides health promotion researchers and practitioners with guidance on how to develop and disseminate community narratives to broaden awareness of social issues and build support for particular programs and policy solutions. To exemplify the community narrative development process and highlight important considerations, this article examines a narrative from a mental health consumer-run organization. In the narrative, people with mental health problems help one another while operating a nonprofit organization, thereby countering stigmatizing media portrayals of people with mental illness as dangerous and incompetent. The community narrative frame supports the use of consumer-run organizations, which are not well-known and receive little funding despite evidence of effectiveness. The article concludes by reviewing challenges to disseminating community narratives, such as creating a product of interest to media outlets, and potential solutions, such as engaging media representatives through community health partnerships and using social media to draw attention to the narratives.

Engaging vulnerable populations in parent-led support groups: Testing a recruitment strategy

Despite the proven benefits of parenting interventions, parent engagement in such interventions remains low and is particularly challenging among vulnerable populations. This theoretically grounded study tested the effectiveness of a recruitment strategy - a simulated parent-led support group (PSG) - to increase intentions to attend a PSG in a predominantly low income, minority sample. The study also examined sociodemographic characteristics that may influence the effectiveness of the recruitment strategy and engagement in PSGs. Surveys assessing intentions to attend a PSG were administered before and after the simulation, and a 2-month follow-up survey assessed subsequent PSG attendance. A total of 95 participants were included in this study. Results indicate that participants' intentions to attend a PSG significantly increased following the PSG simulation (Cohen's d = 1.15), especially among Hispanics. However, PSG attendance in the 2 months following the PSG simulation was relatively low, with only 13% of parents attending a PSG or a planning meeting to start a new PSG. Nevertheless, this recruitment strategy may serve as an important component of a larger engagement effort, especially given the substantial challenges of engaging vulnerable populations in PSGs and other parenting interventions to reduce educational and health disparities.

Evaluation of Healthy Fit: A Community Health Worker Model to Address Hispanic Health Disparities

Introduction

Hispanics in the United States have disproportionately high rates of obesity, hypertension, and diabetes and poorer access to preventive health services. Healthy Fit uses community health workers to extend public health department infrastructure and address Hispanic health disparities related to cardiovascular disease and access to preventive health services. We evaluated the effectiveness of Healthy Fit in 1) reaching Hispanic Americans facing health disparities, and 2) helping participants access preventive health services and make behavior changes to improve heart health.

Methods

Community health workers recruited a sample of predominantly low-income Hispanic immigrant participants (N = 514). Following a health screening, participants received vouchers for breast, cervical, and colorectal cancer screening, and received vaccinations as needed for influenza, pneumonia, and human papillomavirus. Participants who were overweight or had high blood pressure received heart health fotonovelas and referrals to community-based exercise activities. Community health workers completed follow-up phone calls at 1, 3, and 6 months after the health screening to track participant uptake on the referrals and encourage follow-through.

Results

Participants faced health disparities related to obesity and screening for breast, cervical, and colorectal cancer. Postintervention completion rates for breast, cervical, and colorectal cancer screening were 54%, 43%, and 32%, respectively, among participants who received a voucher and follow-up phone call. Among participants with follow-up data who were overweight or had high blood pressure, 70% read the fotonovela, 66% completed 1 or more heart health activities in the fotonovela, 21% attended 1 or more community-based exercise activities, and 79% took up some other exercise on their own.

Conclusion

Healthy Fit is a feasible and low-cost strategy for addressing Hispanic health disparities related to cancer and cardiovascular disease.

Effects of Sectoral Diversity on Community Coalition Processes and Outcomes

Collaboration with diverse partners is challenging but essential for the implementation of prevention programs and policies. Increased communication with partners from diverse sectors may help community coalitions overcome the challenges that diversity presents. We examined these issues empirically in a study of 17 substance use prevention coalitions in Mexico. Building on coalition and workgroup literatures, we hypothesized that sectoral diversity would improve outcomes but undermine coalition processes. Conversely, we expected uniformly positive effects from higher levels of intersectoral communication. Data are from a 2015 survey of 211 members within the 17 community coalitions. Regression models used sectoral diversity and intersectoral communication to predict coalition processes (cohesion, leader-member communication, efficiency) and outcomes (community support, community improvement, sustainability planning). Sectoral diversity was negatively associated with coalition processes and was not associated with coalition outcomes. Intersectoral communication was positively associated with two of the three measures of coalition outcomes but not associated with coalition processes. Our findings concur with those from prior research indicating that sectoral diversity may undermine coalition processes. However, more communication between sectors may facilitate the coalition outcomes of community support and sustainability planning. Skilled team leaders and participatory decision making may also help coalitions promote intersectoral communication, thereby engaging diverse community sectors to implement preventive interventions and actualize sustained public health impact.

Neonatal outcomes after introduction of a national intrapartum fetal surveillance education program: a retrospective cohort study

OBJECTIVE

To determine the impact of a multidisciplinary fetal surveillance education program (FSEP) on term neonatal outcomes.

METHODS

A retrospective cohort study of term neonatal outcomes before (1998-2004) and after (2005-2010) introduction of a FSEP. Clinical data was collected for all term infants admitted to a neonatal intensive care unit (NICU) in Australia between 1998 and 2010. Infants with congenital abnormalities were excluded. Neonatal mortality and severe neonatal morbidity (admission to a NICU, respiratory support, hypoxic encephalopathy) were compared before and after the FSEP was introduced. The rates of operative delivery during this time were assessed.

RESULTS

There were 3 512 596 live term births between 1998 and 2010. The intrapartum hypoxic death rate at term decreased from 2.02 to 1.07 per 10 000 total births. More neonates were admitted to NICU after 2005 (10.6 versus 14.6 per 10 000 live births), however fewer babies admitted to the neonatal unit had Apgar scores < 5 at five minutes (55.1-45.5%, RR 0.82, 95% CI 0.7-0.87); and rates of hypoxic ischemic encephalopathy fell from 36% to 30% (RR 0.83, 95% CI 0.76-0.90). There was no increase in rates of emergency in labour caesarean sections (11.7% pre versus 11.1% post, RR 0.95, 95% CI 0.95-0.96).

CONCLUSIONS

Introduction of a national FSEP was associated with increased neonatal admissions but a reduction in intrapartum hypoxia, without increasing emergency caesarean section rates.

Financial Barriers to Health Care Among Mexican Americans With Chronic Disease and Depression or Anxiety in El Paso, Texas

PURPOSE

To determine the barriers to health care access by chronic disease and depression/anxiety diagnosis in Mexican Americans living in El Paso, TX.

DESIGN

A secondary analysis was conducted using data for 1,002 Hispanics from El Paso, TX (2009-2010). Logistic regression was conducted for financial barriers by number of chronic conditions and depression/anxiety diagnosis. Interaction models were conducted between number of chronic conditions and depression or anxiety.

RESULTS

Depressed/anxious individuals reported more financial barriers than those with chronic conditions alone. There were significant interactions between number of chronic conditions and depression/anxiety for cost, denied treatment because of an inability to pay, and an inability to pay $25 for health care.

CONCLUSION

Financial barriers should be considered to maintain optimal care for both mental and physical health in this population.

IMPLICATIONS FOR PRACTICE

There should be more focus on the impact of depression or anxiety as financial barriers to compliance.

Community Prevention Coalition Context and Capacity Assessment: Comparing the United States and Mexico

Effective planning for community health partnerships requires understanding how initial readiness-that is, contextual factors and capacity-influences implementation of activities and programs. This study compares the context and capacity of drug and violence prevention coalitions in Mexico to those in the United States. Measures of coalition context include community problems, community leadership style, and sense of community. Measures of coalition capacity include the existence of collaborative partnerships and coalition champions. The assessment was completed by 195 members of 9 coalitions in Mexico and 139 members of 7 coalitions in the United States. Psychometric analyses indicate the measures have moderate to strong internal consistency, along with good convergent and discriminant validity in both settings. Results indicate that members of Mexican coalitions perceive substantially more serious community problems, especially with respect to education, law enforcement, and access to alcohol and drugs. Compared to respondents in the United States, Mexican respondents perceive sense of community to be weaker and that prevention efforts are not as valued by the population where the coalitions are located. The Mexican coalitions appear to be operating in a substantially more challenging environment for the prevention of violence and substance use. Their ability to manage these challenges will likely play a large role in determining whether they are successful in their prevention efforts. The context and capacity assessment is a valuable tool that coalitions can use in order to identify and address initial barriers to success.

Comparing the Functioning of Youth and Adult Partnerships for Health Promotion

Youth partnerships are a promising but understudied strategy for prevention and health promotion. Specifically, little is known about how the functioning of youth partnerships differs from that of adult partnerships. Accordingly, this study compared the functioning of youth partnerships with that of adult partnerships. Several aspects of partnership functioning, including leadership, task focus, cohesion, participation costs and benefits, and community support, were examined. Standardized partnership functioning surveys were administered to participants in three smoke-free youth coalitions (n = 44; 45 % female; 43 % non-Hispanic white; mean age = 13) and in 53 Communities That Care adult coalitions (n = 673; 69 % female; 88 % non-Hispanic white; mean age = 49). Multilevel regression analyses showed that most aspects of partnership functioning did not differ significantly between youth and adult partnerships. These findings are encouraging given the success of the adult partnerships in reducing community-level rates of substance use and delinquency. Although youth partnership functioning appears to be strong enough to support effective prevention strategies, youth partnerships faced substantially more participation difficulties than adult partnerships. Strategies that youth partnerships can use to manage these challenges, such as creative scheduling and increasing opportunities for youth to help others directly, are discussed.

Unintended birth among Hispanic women in Texas: a descriptive analysis

Unintended birth is associated with adverse maternal and infant outcomes. In 2006, US Hispanics had the highest unintended birth rate (45 births/1,000 women) compared to other groups. One-fifth of US Hispanic women reside in Texas, yet unintended birth among Texas Hispanics has not been studied. The goal of this study was to describe the prevalence and characteristics of unintended birth in this population. Using data from Hispanic participants in the Texas Pregnancy Risk Assessment Monitoring System 2009-2010, we studied unintended birth in relation to demographic, lifestyle and partner characteristics. Adjusted prevalence odds ratios (POR) were computed for each characteristic and the analysis was stratified by maternal nativity (US vs foreign born). The weighted proportion of unintended birth was 49.5 % (CI = 45.9-52.6). In adjusted analyses, women aged 12-19 had a higher prevalence of unintended birth compared to ≥20 years (POR = 2.1, CI = 1.3-3.7). Unmarried (POR = 1.5, CI = 1.1-2.1), uninsured (POR = 1.7, CI = 1.2-2.3), and US-born (POR = 1.6, CI = 1.0-2.6) women had higher prevalence compared to married, insured and foreign-born women, respectively. Among US-born Hispanic women, higher prevalence of unintended birth was associated with being young, unmarried and experiencing psychological stressors within 12 months of giving birth; among foreign-born Hispanic women, higher prevalence was associated with lack of insurance. Efforts to reduce unintended birth in Texas might focus on young, single, uninsured and US-born Hispanic women. Analyses of other pre-pregnancy factors and health outcomes among Texas Hispanics could increase understanding of the differences we observed in unintended birth between US and foreign-born Hispanics.

The structure of social exchange in self-help support groups: development of a measure

Self-help support groups are indigenous community resources designed to help people manage a variety of personal challenges, from alcohol abuse to xeroderma pigmentosum. The social exchanges that occur during group meetings are central to understanding how people benefit from participation. This paper examines the different types of social exchange behaviors that occur during meetings, using two studies to develop empirically distinct scales that reliably measure theoretically important types of exchange. Resource theory informed the initial measurement development efforts. Exploratory factor analyses from the first study led to revisions in the factor structure of the social exchange scales. The revised measure captured the exchange of emotional support, experiential information, humor, unwanted behaviors, and exchanges outside meetings. Confirmatory factor analyses from a follow-up study with a different sample of self-help support groups provided good model fit, suggesting the revised structure accurately represented the data. Further, the scales demonstrated good convergent and discriminant validity with related constructs. Future research can use the scales to identify aspects of social exchange that are most important in improving health outcomes among self-help support group participants. Groups can use the scales in practice to celebrate strengths and address weaknesses in their social exchange dynamics.

Rural Embedded Assistants for Community Health (REACH) network: first-person accounts in a community-university partnership

Community research and action projects undertaken by community-university partnerships can lead to contextually appropriate and sustainable community improvements in rural and urban localities. However, effective implementation is challenging and prone to failure when poorly executed. The current paper seeks to inform rural community-university partnership practice through consideration of first-person accounts from five stakeholders in the Rural Embedded Assistants for Community Health (REACH) Network. The REACH Network is a unique community-university partnership aimed at improving rural health services by identifying, implementing, and evaluating innovative health interventions delivered by local caregivers. The first-person accounts provide an insider's perspective on the nature of collaboration. The unique perspectives identify three critical challenges facing the REACH Network: trust, coordination, and sustainability. Through consideration of the challenges, we identified several strategies for success. We hope readers can learn their own lessons when considering the details of our partnership's efforts to improve the delivery infrastructure for rural healthcare.

Relating engagement to outcomes in prevention: the case of a parenting program for couples

Analyses of program engagement can provide critical insight into how program involvement leads to outcomes. This study examines the relation between participant engagement and program outcomes in Family Foundations (FF), a universal preventive intervention designed to help couples manage the transition to parenthood by improving coparenting relationship quality. Previous intent-to-treat outcome analyses from a randomized trial indicate FF improves parental adjustment, interparental relationships, and parenting. Analyses for the current study use the same sample, and yield statistically reliable relations between participant engagement and interparental relationships but not parental adjustment or parenting. Discussion considers implications for FF and the difficulties researchers face when examining the relation between engagement and outcomes in preventive interventions.

Predicting engagement in a transition to parenthood program for couples

Fostering participant engagement is a challenging but essential component of effective prevention programs. To better understand which factors influence engagement, this study examines several predictors of couple engagement in Family Foundations (FF), a preventive intervention for first-time parents shown to enhance parent mental health, couple relations, parenting quality, and child adjustment through age 3 years. FF consists of a series of classes delivered through childbirth education departments at local hospitals. Baseline data on socio-demographics, parent mental health, and couple relationship quality were examined as predictors of participants' level of engagement in FF (n = 89 couples, 178 individuals). Sociodemographic variables such as parent gender, socioeconomic status, and age predicted program engagement to a limited extent. However, findings indicated that marital status was the best predictor of engagement. Discussion focuses on how findings can inform the development of practices that promote engagement, such as the use of targeted outreach efforts for individuals most at risk of disengagement.

A Multi-Domain Self-Report Measure of Coparenting

OBJECTIVE: This study reports the psychometric properties of a multi-domain measure of the coparenting relationship in dual-parent families. METHOD: 152 couples participating in a transition to parenthood study completed the Coparenting Relationship Scale and additional measures during home visits at child age 6 months, 1 year, and 3 years. RESULTS: Psychometric and construct validity assessments indicated the measure performed satisfactorily. The 35-item measure demonstrated good reliability and strong stability. Subscales measuring theoretically and empirically important aspects of coparenting (coparenting agreement, coparenting closeness, exposure of child to conflict, coparenting support, coparenting undermining, endorsement of partner's parenting, and division of labor) demonstrated good reliability as well. A 14-item brief overall measure showed very strong associations with the overall measure. Relations of the full scale with a measure of social desirability were weak, and the full scale was positively associated with positive dimensions of the dyadic couple relationship (love, sex/romance, couple efficacy) and inversely associated with negative dimensions (conflict, ineffective arguing)-as expected. CONCLUSIONS: This initial examination of the Coparenting Relationship Scale suggests that it possesses good psychometric properties (reliability, stability, construct validity, and inter-rater agreement), can be flexibly administered in short and long forms, and is positioned to promote further conceptual and methodological progress in the study of coparenting.

Measuring coalition functioning: refining constructs through factor analysis

Internal and external coalition functioning is an important predictor of coalition success that has been linked to perceived coalition effectiveness, coalition goal achievement, coalition ability to support evidence-based programs, and coalition sustainability. Understanding which aspects of coalition functioning best predict coalition success requires the development of valid measures of empirically unique coalition functioning constructs. The goal of the present study is to examine and refine the psychometric properties of coalition functioning constructs in the following six domains: leadership, interpersonal relationships, task focus, participation benefits/costs, sustainability planning, and community support. The authors used factor analysis to identify problematic items in our original measure and then piloted new items and scales to create a more robust, psychometrically sound, multidimensional measure of coalition functioning. Scales displayed good construct validity through correlations with other measures. Discussion considers the strengths and weaknesses of the refined instrument.

Determinants of community coalition ability to support evidence-based programs

This study examines how aspects of coalition functioning predict a coalition's ability to promote high-quality implementation of evidence-based programs (EBPs). The study involved 62 Communities That Care (CTC) coalitions in Pennsylvania measured annually from 2003 to 2007. Findings indicate that the communities with higher levels of poverty and longer existing coalitions are related to lower support for high-quality EBP implementation. Several aspects of coalition functioning-including higher levels of funding; leadership strength; board efficiency; strong internal and external relationships; and fidelity to the CTC model-significantly predicted support for high-quality EBP implementation. Earlier measurements of coalition functioning (2003-2004 and 2005-2006) predicted EBP implementation (2007) more strongly than concurrent coalition assessments (2007). The discussion focuses on how coalitions and technical assistance providers can improve coalition support for the implementation of EBPs.

How people can benefit from mental health consumer-run organizations

The goal of this study is to develop a more comprehensive theoretical understanding of the processes by which people can benefit from mental health consumer-run organizations (CROs). To accomplish this goal, the concept of roles is used to create a preliminary framework that draws connections between several established theoretical explanations. To ground theory development in empirical data, 194 CRO members from 20 CROs answered open-ended questions about what personal changes occurred as a result of their CRO involvement and what CRO participation experiences enabled personal change. Data analysis led to the identification of 18 personal change categories and 7 experiences that led to change. These categories were integrated into the preliminary theoretical framework, which needed to be extended to accommodate all categories. While inevitably tentative, the final conceptualization provides a more comprehensive understanding of the processes by which people can benefit from CRO participation.

Making it sane: using narrative to explore theory in a mental health consumer-run organization

My previous research led to the development of a theoretical model explaining the processes by which people can benefit from consumer-run organizations (CROs). This study builds on that work by exploring the ability of the conceptual framework to capture the complexity of seven diverse life history narratives from participants at one CRO. To construct life history narratives, I used data from participant observation and a series of in-depth, minimally structured interviews. Application of the proposed conceptual framework to the narratives provides a consistent structure that organizes the experiences of informants into meaningful components. This application of the framework to the data also enables an exploration of the framework's ability to account for the lives of all informants. This analysis leads to conclusions on the conceptual framework's ability to explain how people benefit from CROs.

Introduction to the special issue on mental health self-help

Since the 1950s, people with mental illness and their families have been organizing a wide range of self-directed, mutual support oriented initiatives, including self-help groups, nonprofit organizations, and businesses. These initiatives have become increasingly widespread over the years and today mental health self-help initiatives outnumber traditional mental health organizations in the United States (Goldstrom et al., Admin Policy Mental Health Mental Health Serv Res 33:92-103, 2006). Mental health self-help embodies much of what community psychologists promote, including the self-directed organization of people to create social change and facilitate personal transformation. This special issue provides new insight into several prominent areas of inquiry surrounding these low-cost interventions including: (1) their evidence base; (2) the processes by which people benefit; (3) how they interface with the mental health system; and (4) the value dilemmas they face.

Understanding how participation in a consumer-run organization relates to recovery

The goal of this study was to examine how different types of participation in a consumer-run organization (CRO) are related to recovery. More specifically, this study uses structural equation modeling to examine the relative impact of empowering and socially supportive participation experiences on progress towards recovery among 250 CRO members from 20 CROs. An empowering participation experience refers to involvement in leadership roles and contribution to organizational functioning. A socially supportive participation experience refers to social involvement in mutually supportive friendships with intimacy and sharing. Results indicate that both types of participation are associated with recovery, although a socially supportive participation experience maintains a stronger relationship with recovery than an empowering participation experience. Findings are consistent with the idea that CROs should encourage both types of participation. Drawing from over ten years of experience supporting CROs, the discussion section explores several strategies CROs can use to foster empowering and socially supportive participation experiences.

Goal Achievement and the Accountability of Consumer-Run Organizations

This study explores how consumer-run organizations (CROs) can maintain independence while meeting the accountability needs of funding agencies. The importance of both funding agency needs for accountability and CRO needs for independence are discussed. A goal-tracking process is proposed as a potential strategy for balancing the potentially conflicting needs of accountability and independence. To demonstrate the utility of the goal tracking approach, this study analyzes goal tracking documentation in 3 years of quarterly reports from 21 CROs (also known as consumer drop-in centers and self-help agencies). Results detail the different goals of CROs. A 68% goal achievement rate suggests general organizational competence. Furthermore, CRO operations appear to be relatively cost-efficient, with an average of $11.51 spent per person per day. The analysis of quarterly reports leads to a discussion of several insights that may be useful to CROs, funding agencies, researchers, and mental health professionals.

Delayed dedifferentiation and retention of properties in dissociated adult skeletal muscle fibers in vitro

Adult skeletal muscle fibers can be isolated and cultured but tend to dedifferentiate and sprout with time in culture. We examined isolated adult mouse flexor digitorum brevis muscle fibers under various culture conditions by monitoring maintenance of the same fibers at 2-d intervals using survival analysis. Fibers plated on laminin and cultured in serum-free media did not show sprouting and exhibited significantly (P < 0.0001) longer survival (median survival time, T(50) = 10.2 d) than fibers in serum-containing media (T(50) = 3.3 d). Cell proliferation was markedly suppressed in serum-free cultures. Multiple or delayed Ca(2+) transients in response to brief field stimulation were often observed in dedifferentiated fibers after several d in serum-containing media but were not observed in fibers in serum-free media. The addition of cytosine arabinoside to serum-containing cultures did not prolong fiber survival (P = 0.39) and did not eliminate sprouting but did greatly suppress proliferation of nonmuscle cells. Fibers cultured in agarose gel with serum exhibited small, bud-like extensions but no sprouts and did not survive as long (T(50) = 6.2 d) as fibers plated on laminin and cultured in serum-free media (T(50) = 10.2 d) did. These results demonstrate that both morphological and physiological properties of fibers become modified in serum-containing media but can be retained by culturing without serum.

Nonuniform distribution of myosin light chains within the thick filaments of lobster slow muscle: Immunocytochemical study

The in situ distribution of the alpha and beta myosin light chains was investigated at the subsarcomeric and subfilament levels in individual fibers of the superficial flexor muscle (SFM) of the lobster, Homarus americanus. Polyclonal antibodies were produced against the two classes of myosin light chains and used for subsequent immunolocalization on thin sections of sarcomeres and on isolated filaments from both the medial and lateral fiber bundles of the SFM. The beta myosin light chains were uniformly distributed within the crossbridge region of sarcomeres of both medial and lateral bundles. The alpha myosin light chains were uniformly distributed within the crossbridge region of sarcomeres from the medial bundle, but were nonuniformly distributed over the crossbridge region of lateral bundle sarcomeres. In the latter, the number of alpha myosin light chains was highest toward the center of the thick filaments, diminishing towards the ends. Similar distributions of alpha light chains were found in isolated myosin filaments. These data demonstrate that heterogeneity in protein composition extends to the level of the myosin filament and suggest that the myosin filament substructure in lobster may be different than that found in vertebrate skeletal muscle.

A-band architecture in vertebrate skeletal muscle: polarity of the myosin head array

Despite extensive knowledge of many muscle A-band proteins (myosin molecules, titin, C-protein (MyBP-C)), details of the organization of these molecules to form myosin filaments remain unclear. Recently the myosin head (crossbridge) configuration in a relaxed vertebrate muscle was determined from low-angle X-ray diffraction (Hudson et al. (1997), J Mol Biol 273: 440-455). This showed that, even without C-protein, the myosin head array displays a characteristic polar pattern with every third 143 A-spaced crossbridge level particularly prominent. However, X-ray diffraction cannot determine the polarity of the crossbridge array relative to the neighbouring actin filaments; information crucial to a proper understanding of the contractile event. Here, electron micrographs of negatively-stained goldfish A-segments and of fast-frozen, freeze-fractured plaice A-bands have been used to determine the resting myosin head polarity relative to the M-band. In agreement with the X-ray data, the prominent 429 A-spaced striations are seen outside the C-zone, where no non-myosin proteins apart from titin are thought to be located. The head orientation is with the concave side of the curved myosin heads (containing the entrance to the ATP-binding site) facing towards the M-band and the convex surface (containing the actin-binding region at one end) facing away from the M-band.

Window shopping: state health reform politics in the 1990s

Throughout the 1990s states sought politically acceptable policies to reduce the ranks of the uninsured. Visions of comprehensive health reform and universal coverage yielded by mid-decade to more modest measures to repair private health insurance markets, and to these enactments were added several new public programs (state and federal) to expand coverage for lower-income children and, in some cases, adults. Because governments remain ill equipped to counter the power of business, insurers, and providers in conflicts fought on private turf, reform agendas have been more readily set, moved, and cleared in public-sector arenas. Although the number of uninsured rose steadily until 1999, "catalytic federalism"--the accelerating interplay between state and federal reform forces and funds--may be putting the programmatic foundations for broader coverage incrementally into place.

An evaluation of the impact of training Honduran health care providers in interpersonal communication

OBJECTIVE

To evaluate the impact of interpersonal communication (IPC) training on practice and patient satisfaction and to determine the acceptability of this training to providers in a developing country.

DESIGN

The study used a pre-post design with treatment and control groups. Data collection methods included interaction analysis of audio-taped clinical encounters, patient exit interviews, and a self-administered questionnaire for health providers.

STUDY PARTICIPANTS

Interaction analysis was based on an experimental group of 24 doctors and a control group of eight with multiple observations for each provider). Exit interviews were carried out with 220 pre-test patients and 218 post-test patients. All 87 health providers who received training responded to the self-administered questionnaire.

INTERVENTION

A brief in-service training programme on interpersonal communications was presented in three half-day sessions; these focused on overall socio-emotional communication, problem solving skills and counselling.

MAIN OUTCOME MEASURES AND RESULTS

The IPC intervention was associated with more communication by trained providers (mean scores of 136.6 versus 94.4; P = 0.001), more positive talk (15.93 versus 7.99; P = 0.001), less negative talk (0.11 versus 0.59; P = 0.018), more emotional talk (15.7 versus 5.5; P = 0.021), and more medical counselling (17.3 versus 11.3; P = 0.026). Patients responded by communicating more (mean scores of 113.8 versus 79.6; P = 0.011) and disclosing more medical information (54.7 versus 41.7; P = 0.002). Patient satisfaction ratings were higher for providers who had received the training and providers reported training to be relevant and useful.

CONCLUSIONS

Further validation of IPC skills and simplification of assessment methods are needed if IPC is to be an area for routine monitoring and quality improvement.

Uneasy alliances: managed care plans formed by safety-net providers

Health care providers that have traditionally served the poor are forming their own managed care plans, often in alliance with local safety-net peers. These alliances make it easier to raise needed capital, increase the pool of likely enrollees, and enable plans to benefit from efficiencies of scale. At the same time, however, the alliances often are undermined by conflicts of interest among the different sponsors and between the sponsors and the plan. This paper suggests that these plans are most likely to do well when the state makes special efforts to help and when plans have the leadership and financial reserves to take advantage of their supportive state policies.

Implementing Medicaid managed care: the New York City story

Across the nation, public officials are encouraging or requiring Medicaid beneficiaries to enroll in managed care. In this article, we report on a study of the implementation of Medicaid managed care in New York City. Several findings are clear. First, government officials need to treat health plans as partners rather than adversaries; in New York, the relationship between the state and the plans is far too adversarial. Second, effective managed care requires good management information systems; New York officials are collecting an enormous amount of data but not much useful information. Third, effective implementation of Medicaid managed care is slow going; New York's effort to dramatically accelerate the enrollment process did not work.

The consequences of treatment and disease in patients with primary CNS non-Hodgkin's lymphoma: cognitive function and performance status. North Central Cancer Treatment Group

Per protocol, patients with primary CNS non-Hodgkin's lymphoma in an intergroup phase II trial conducted by the North Central Cancer Treatment Group and the Eastern Cooperative Oncology Group had their cognitive functions measured using the Folstein and Folstein Mini-Mental Status Examination (MMSE) and their physical functions measured using the Eastern Cooperative Oncology Group Performance Score (PS) at study entry, at each treatment evaluation, and at quarterly intervals thereafter until disease progression or death. Of the 53 eligible participants who began therapy, 46 (87%) had baseline MMSE scores recorded, 36 (68%) had at least one follow-up MMSE, and 32 (60%) had both, while 52 (98%) had baseline PS, 49 (92%) had at least one follow-up PS, and 48 (91%) had both. Patterns of MMSE and PS values over time were studied in each individual, in the group as a whole, in the 20 patients who completed the study regimen, in the 23 who survived more than a year, and in patients who were classified as nonprogressors at each key evaluation. For each patient, all recorded values were plotted versus time, with dates of disease progression and death included, to look for signs of decline in cognitive or physical function preceding adverse events. Long-term declines in scores of both cognitive and physical function were observed in many treated patients with primary CNS non-Hodgkin's lymphoma. Nearly all patients who were alive more than 52 weeks after study entry had a demonstrable decline in cognitive and physical functionality. Such declines may occur before disease progression is documented; they may also occur in some patients who have long-term follow-up without evidence of disease progression. Declining MMSE and PS was a poor predictor of disease progression. There was no association of PS and toxicity. The data from this study demonstrated the considerable difficulties we encountered conducting an ancillary study such as this within a multicenter clinical trial. Firstly, the test instruments written into the protocol were unable to tell if the declines seen were due to disease, treatment, co-morbidity, or other factors. Secondly, the missing data created difficulties in interpreting outcome.